An inquest into the deaths of three former residents of The Elms care home in Whittlesey began at Peterborough Town Hall on March 27. 

Margaret Canham, 97, George Lowlett, 90, and David Poole, 74, who were all living at the care home, died within around a month of each other in early 2019  

The Elms was shut down last year after being rated Inadequate by the Care Quality Commission (CQC). 

Shortly before The Elms’ closure, Cambridgeshire County Council (CCC) suspended admissions not just to The Elms but to all care homes operated by the HC-One provider in the region. 

Representatives of The Elms, the CQC and CCC all gave evidence at the inquest, but not before Caroline Jones heard from Mrs Canham’s granddaughter, Kim Arden. 

READ MORE: Care home was rated ‘inadequate’ by inspectors prior to its closure | Cambs Times

Relative felt ‘lied to and misled’ by home 

Mrs Arden said at the hearing that she felt she was lied to and misled by HC-One, which she also said offered her money. 

She said that Mrs Canham was “subjected to a catalogue of failings” for which she’ll “never forgive” the company and that her grandmother’s final days have left an “imprint on my heart which will never heal. 

At the time of her death, Mrs Arden was already looking into alternative care homes for her grandmother, she said, and had raised concerns about her care. 

In her witness statement, she recounted an incident in which her grandmother’s records at The Elms stated that a head injury she endured was as a result of a TV remote conteol hitting her either because it became tangled in her bed or surrounding wires, but reports to GP’s blamed it on a fall. 

Mrs Arden also said that staffing levels at The Elms were so low that families were given keypad codes to get in and out. 

On the day Mrs Canham was admitted to hospital, Mrs Arden said she went to see the home manager Katie Coulson on site but was told she would have to wait until she had finished a call. 

Mrs Coulson, who also gave evidence to the inquest, said that she immediately left her call to attend to Mrs Arden. 

Mrs Canham died at Peterborough City Hospital where she had been treated for sepsis just over a week after she left The Elms. 

The Elms didn’t have full staffing occupancy 

Giving her evidence, Mrs Coulson confirmed that on some of the dates during which Mrs Canham became ill that the home didn’t have full staffing occupancy but said that it was still operating safely as there were 29 residents there at the time rather than the full 37. 

Mrs Arden, who was allowed to ask each witness questions, told Mrs Coulson that she “can't see anything” on a care home report on her grandmother’s illness and admission to hospital that was correct. 

Mrs Arden said that the times her grandmother was seen, the time the family were informed of her illness and the date the incident began were all incorrect. 

The coroner, meanwhile, noted that it might be “confusing” that information about residents and their health was routinely recorded in four different places at The Elms. 

Relative will ‘never be free of the sight’ of her grandmother’s condition 

Another point of contention occurred over Mrs Canham’s condition on the morning of February 14. 

Mrs Arden said she will “never be free of the sight” of her grandmother sitting bound in a blanket in her chair with her breakfast untouched. 

She took a photo of this, which she says was taken at 10:01am. 

But carer David Redford, one of several care and medical staff involved with Mrs Canham in her final days at the home, said that when he left her room that morning, she had started to eat her breakfast. 

Mr Redford was also the member of staff who took some initial tests and concluded that Mrs Canham should see a GP. 

She saw a nurse later that morning who called the ambulance which took her to hospital with suspected pneumonia. 

According to a witness statement from The Elms Clinical Service Manager Rachel Jolly, Mrs Canham tested negative for infection on February 11, three days earlier, but on February 12-13 had symptoms that meant she required first observation and later the attention of a GP. 

CQC apologises for pace of inspections 

The first day of the inquest concluded with evidence from the CQC and CCC. 

The CQC’s deputy director of operations for the East of England, Hazel Roberts, confirmed that The Elms was inspected in August 2019 after concerns were raised over Mrs Canham’s case and others. 

It was rated Requires Improvement. 

A second full inspection in October 2021 meant that this was downgraded to the lowest level, Inadequate. 

READ MORE: Care company confirms closure of two care homes | Cambs Times

Between these dates, Mrs Arden contacted the CQC nine times providing documents and raising concerns. 

Ms Roberts said that inspectors “should have gone in much sooner” and that she can “only apologise they didn’t”. 

In the same period, Mrs Arden sent complaints to CCC which upheld some of these on the basis that more monitoring work needed to be done. 

Council has concerns about other HC-One homes 

Head of service and contracted provision at CCC Lessa Murray said that “aggregate concerns led us to escalate and suspend admissions to all HC-One homes from July 2022.” 

Asked why the council didn’t visit The Elms sooner, Ms Murray said that the council would allow professionals such as the CQC to carry out safeguarding checks first. 

Donna Glover, assistant director for adult social care at CCC and Peterborough City Council (PCC), said she doesn’t believe there was anything the council could have done in the lead up to Mrs Canham’s death that would have changed the outcome. 

These CCC representatives, as well as Ms Robers and Mrs Coulson, are expected to give further evidence later this week. 

Ms Canham’s inquest is the first of three being held back-to-back and will conclude today (March 28). 

Evidence regarding the deaths of Mr Lowlett and Mr Poole will follow. 

The inquest continues.